PET INTAKE FORM
2010 Arcadia Street, Fort Myers, Florida 33916
Ofce: (239) 332-0364 Fax: (239) 332-8676
Owner Name _____________________________________________________ Phone ______________________
Address _______________________________________ City ________________ State _____ Zip ___________
Date ____________ Personnel Intake Name
Pet’s Name ____________________________ Feline Canine Pocket Pet Breed ___________________
Color ________________________ Age / D.O.B ______________________ Sex _____ Fixed _________________
Microchip ______________________________ Up to date on vaccines? YES NO (Attach vaccine records)
Vet Name: _____________________________ Vet Phone Number: _____________________
Why are you surrendering your pet? _______________________________________________________________
Where did you acquire your pet? ___________________________How long have you had your pet? ____________
Is you animal current on Heart-worm / Flea Prevention YES NO When last given _____________________
Does your pet have any current or past health conditions or injuries? If so-list below and attach medical records.
____________________________________________________________________________________________
Who does your pet get along with? MEN WOMEN CHILDREN (ages)______ DOGS CATS
Has your pet ever shown signs of aggression? YES NO
If yes, was it provoked? Please explain ____________________________________________________________
Does your pet live Indoors, Outdoors or both _____________What type of food does your pet eat? _____________
Any destructive habits? YES NO If yes, explain _________________________________ _________________ Is
your pet house broken / Litter trained? YES NO Obedience training YES NO
Please tell us about your pet and any special characteristic personality traits, or special needs:
____________________________________________________________________________________________
STATEMENT OF SURRENDER
Additional Space on back if needed
I certify that I do___/ do not___ own the animal described above and hereby surrender all interest to the Gulf Coast Humane
Society. My interest in this animal has now been voided and I will not be given any information on the welfare or disposition of this
animal. Initials_________
There is no minimum set time for holding this animal. The holding time depends on the animal’s health, behavior and adoptability. It
is also agreed that neither said society nor its management and employees shall incur any obligation to me on the disposition of the
above listed animal. I certify that this animal has not bitten another animal or human within the last 10 days.
I have read and understand that I have surrendered my rights and interest towards this animal.
Signature __________________________________________________________ Date ______________________________
I would like to make a donation in the amount of $ __________________________ to the Gulf Coast Humane Society to assist in
the care of the animals in need.
Signature __________________________________________________________ Date ______________________________
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